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An analysis of the results and conclusions from the most recent RCTs of the role of mechanical bowel preparation before colonic surgery is presented. A multicentre (4 hospitals), parallel, single-blinded trial was undertaken in patients undergoing colonic resection who were assigned randomly (1: 1) to either mechanical oral antibiotic bowel preparation or no bowel preparation[5]. Patients with colorectal cancer scheduled for elective curative surgery, considered high-risk patients, were included. Although the Dutch study emphasized the emerging role of the microbiome in pathogenesis of AL and the important role that collagenolytic pathogens may play in this complication, is it not time to document this patient by patient and make appropriate changes to the antibiotic regimen?. [Extracted from the article]

Aim Reservoir ileitis (pouchitis) is the most common complication after pelvic pouch surgery for ulcerative colitis and the aetiology remains largely unknown. The anal transition zone ( ATZ) contains the only remaining colonic epithelium after ileal pouch anal anastomosis ( IPAA) and may provide important clues as to whether ulcerative colitis and pouchitis share a common pathogenesis. The aim of this study was to evaluate longitudinally the long-term histological changes in the ATZ and their relationship to the incidence of pouchitis. Method Patients with a double-stapled IPAA for ulcerative colitis at an academic medical centre with at least 10 years of clinical and histological follow-up were identified from a prospective database. Annual ATZ and pouch biopsies were taken and interpreted by two expert gastrointestinal pathologists. ATZ histological variability score, the incidence of pouchitis, and function were correlated over time. ATZ biopsies were scored from one to three based on the extent of inflammation. Results Sixteen of the 114 patients having IPAA fulfilled the criteria for admission to the study. There were 179 biopsies of the ATZ. All exhibited variability in ATZ histology over time and 81% had a 2-unit change in their inflammatory score. There was no correlation between pouchitis and histological severity score of the ATZ. Similarly, function over time did not vary with the intensity of ATZ inflammation. Conclusion ATZ inflammation varies substantially over time in most patients. But these changes from year to year did not correlate with function or the occurrence of pouchitis. [ABSTRACT FROM AUTHOR]

Aim Stage-specific survival for colon cancer is improved when more lymph nodes are identified in the surgical specimen. This association is typically attributed to staging effect, but may instead be a surrogate for tumour biology. Method We retrospectively studied a cohort of 48 consecutively treated patients with Stage II colon cancer who underwent complete resection between January 2000 and December 2002. Archived H&E slides were reviewed for lymphocytic infiltration at the leading edge, presence and degree of sinus histiocytosis in the largest node and the presence of lymph node hyperplasia. Results The mean number of lymph nodes identified was 14.1 ± 9.4. T stage was strongly associated with the number of nodes identified ( P = 0.01) and the presence of a significant degree of sinus histiocytosis approached statistical significance ( P = 0.077). No statistically significant relationship existed between number of lymph nodes in a specimen and tumour location ( P = 0.44), grade ( P = 0.56) or lymphovascular invasion ( P = 0.64). Conclusions T stage is highly associated with the number of nodes found in a colon cancer specimen; a significant degree of sinus histiocytosis may also be predictive. Finding more nodes may be a surrogate for tumour or host-related factors that impact prognosis. [ABSTRACT FROM AUTHOR]

A leaking intestinal anastomosis is typically regarded as a devastating post-operative complication. The reported incidence ofanastomotic leakage is highly variable and depends on the definitions used and the anatomical location involved. Early leaks are usually readily diagnosed and aggressive management is warranted. Late leaks may be unrecognised and are likely to be underreported in the literature; diagnosis and treatment in this setting requires a thoughtful, individualised approach. [ABSTRACT FROM AUTHOR]

A leaking intestinal anastomosis is typically regarded as a devastating post-operative complication. The reported incidence of anastomotic leakage is highly variable and depends on the definitions used and the anatomical location involved. Early leaks are usually readily diagnosed and aggressive management is warranted. Late leaks may be unrecognised and are likely to be underreported in the literature; diagnosis and treatment in this setting requires a thoughtful, individualised approach. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Histiocytic infiltration in ulcerative colitis, stimulating malignancy," by D. J. Farrell, D. W. Birchley and C. M. Edwards in the 2004 issue of Histopathology.

Background: The pathogenesis of colorectal cancer recurrence after a curative resection remains poorly understood. A yet‐to‐be accounted for variable is the composition and function of the microbiome adjacent to the tumour and its influence on the margins of resection following surgery. Methods: PubMed was searched for historical as well as current manuscripts dated between 1970 and 2017 using the following keywords: ‘colorectal cancer recurrence’, ‘microbiome’, ‘anastomotic leak’, ‘anastomotic failure’ and ‘mechanical bowel preparation’. Results: There is a substantial and growing body of literature to demonstrate the various mechanisms by which environmental factors act on the microbiome to alter its composition and function with the net result of adversely affecting oncological outcomes following surgery. Some of these environmental factors include diet, antibiotic use, the methods used to prepare the colon for surgery and the physiological stress of the operation itself. Conclusion: Interrogating the intestinal microbiome using next‐generation sequencing technology has the potential to influence cancer outcomes following colonic resection. [ABSTRACT FROM AUTHOR]

The author examines the study "Nature, Causes and Consequences of Unintended Events in Surgical Units," conducted by I. van Wagtendonk and other researchers in the Netherlands between 2006 and 2007. While he notes that no single modality such as voluntary reporting or patient record review is enough for adequately defining the causes of medical error, he observes that the study's detailed analysis of unintended medical events could help hospitals identify more opportunities for improving patient care and safety.

Background: Both obesity and the presence of collagenolytic bacterial strains (Enterococcus faecalis) can increase the risk of anastomotic leak. The aim of this study was to determine whether mice chronically fed a high‐fat Western‐type diet (WD) develop anastomotic leak in association with altered microbiota, and whether this can be mitigated by a short course of standard chow diet (SD; low fat/high fibre) before surgery. Methods: Male C57BL/6 mice were assigned to either SD or an obesogenic WD for 6 weeks followed by preoperative antibiotics and colonic anastomosis. Microbiota were analysed longitudinally after operation and correlated with healing using an established anastomotic healing score. In reiterative experiments, mice fed a WD for 6 weeks were exposed to a SD for 2, 4 and 6 days before colonic surgery, and anastomotic healing and colonic microbiota analysed. Results: Compared with SD‐fed mice, WD‐fed mice demonstrated an increased risk of anastomotic leak, with a bloom in the abundance of Enterococcus in lumen and expelled stool (65–90 per cent for WD versus 4–15 per cent for SD; P = 0·010 for lumen, P = 0·013 for stool). Microbiota of SD‐fed mice, but not those fed WD, were restored to their preoperative composition after surgery. Anastomotic healing was significantly improved when WD‐fed mice were exposed to a SD diet for 2 days before antibiotics and surgery (P < 0·001). Conclusion: The adverse effects of chronic feeding of a WD on the microbiota and anastomotic healing can be prevented by a short course of SD in mice. Surgical relevanceWorldwide, enhanced recovery programmes have developed into standards of care that reduce major complications after surgery, such as surgical‐site infections and anastomotic leak. A complementary effort termed prehabilitation includes preoperative approaches such as smoking cessation, exercise and dietary modification.This study investigated whether a short course of dietary prehabilitation in the form of a low‐fat/high‐fibre composition can reverse the adverse effect of a high‐fat Western‐type diet on anastomotic healing in mice.Intake of a Western‐type diet had a major adverse effect on both the intestinal microbiome and anastomotic healing following colonic anastomosis in mice. This could be reversed when mice received a low‐fat/high‐fibre diet before operation.Taken together, these data suggest that dietary modifications before major surgery can improve surgical outcomes via their effects on the intestinal microbiome. [ABSTRACT FROM AUTHOR]

Background: Previous work has demonstrated that anastomotic leak can be caused by collagenolytic bacteria such as Enterococcus faecalis via an effect on wound collagen. In humans, E. faecalis is the organism cultured most commonly from a leaking anastomosis, and is not routinely eliminated by standard oral or intravenous antibiotics. Novel strategies are needed to contain the virulence of this pathogen when present on anastomotic tissues. Methods: Polyphosphorylated polymer ABA‐PEG20k‐Pi20 was tested in mice for its ability to prevent anastomotic leak caused by collagenolytic E. faecalis. The study design included a distal colonic resection and anastomosis followed by introduction of E. faecalis to anastomotic tissues via enema. Mice were assigned randomly to receive either ABA‐PEG20‐Pi20 or its unphosphorylated precursor ABA‐PEG20k in their drinking water. The development of anastomotic leak was determined after the animals had been killed. Results: Overnight incubation of two different E. faecalis collagenolytic strains with 2 mmol/l of ABA‐PEG20k‐Pi20 led to near complete inhibition of collagenase production (from 21 000 to 1000 and from 68 000 to 5000 units; P < 0·001; 6 samples per group) without suppressing bacterial growth. In mice drinking 1 per cent ABA‐PEG20k‐Pi20, the phosphate concentration in the distal colonic mucosa increased twofold and leak rates decreased from eight of 15 to three of 15 animals (P < 0·001). In mice drinking ABA‐PEG20k‐Pi20, the percentage of collagenolytic colonies among E. faecalis populations present at anastomotic tissue sites was decreased by 6–4800‐fold (P = 0·008; 5 animals). Conclusion: These data indicate that oral intake of ABA‐PEG20k‐Pi20 may be an effective agent to contain the virulence of E. faecalis and may prevent anastomotic leak caused by this organism. Clinical relevance Progress in understanding the pathogenesis of anastomotic leak continues to point to intestinal bacteria as key causative agents. The presence of pathogens such as Enterococcus faecalis that predominate on anastomotic tissues despite antibiotic use, coupled with their ability to produce collagenase, appears to alter the process of healing that leads to leakage. Further antibiotic administration may seem logical, but carries the unwanted risk of eliminating the normal microbiome, which functions competitively to exclude and suppress the virulence of pathogens such as E. faecalis. Therefore, non‐antibiotic strategies that can suppress the production of collagenase by E. faecalis without affecting its growth, or potentially normal beneficial microbiota, may have unique advantages. The findings of this study demonstrate that drinking a phosphate‐based polymer can achieve the goal of preventing anastomotic leak by suppressing collagenase production in E. faecalis without affecting its growth. [ABSTRACT FROM AUTHOR]

Introduction: Angiostatin and endostatin are endogenous inhibitors of angiogenesis with anticancer effects. After minimally invasive colorectal resection (MICR), blood levels of the proangiogenic factors vascular endothelial growth factor (VEGF) and angiopoetin 2 (Ang-2) are elevated for 2-4 weeks. Also, postoperative human plasma from weeks 2 and 3 after MICR has been shown to stimulate endothelial cell proliferation and migration, which are critical to angiogenesis. This proangiogenic state may stimulate tumor growth early after MICR. Surgery's impact on angiostatin and endostatin is unknown. This study's purpose is to determine perioperative plasma levels of these two proteins in colorectal cancer (CRC) patients undergoing MICR.Methods: Endostatin levels were assessed in 34 CRC patients and angiostatin levels in 30 CRC patients. Blood samples were taken preoperatively and on postoperative day (POD) 1 and 3 in all patients; in a subset, samples were taken between POD 7 and 20. The late samples were bundled into 7-day blocks (POD 7-13, POD 14-20) and considered as single time points. Angiostatin and endostatin plasma levels were determined via enzyme-linked immunosorbent assay (ELISA) in duplicate. Wilcoxon signed-rank test and Student's t test were used to analyze endostatin and angiostatin data, respectively. Significance was set at P<0.0125 (after Bonferroni correction).Results: There was a significant decrease in median plasma endostatin levels on POD 1, which returned to the preoperative level by POD 3. There was no significant difference between pre- and postoperative plasma angiostatin levels.Conclusions: MICR has a very transient impact on plasma levels of endostatin and no impact on angiostatin during the first 21 days following surgery. Thus, angiostatin and endostatin do not likely contribute to or inhibit the persistent proangiogenic changes noted after MICR. [ABSTRACT FROM AUTHOR]

Plasma VEGF levels increase after minimally invasive colorectal resection (MICR) and remain elevated for 2–4 weeks. VEGF induces physiologic and pathologic angiogenesis by binding to endothelial cell (EC) bound VEGF-Receptor-1 (VEGFR1) and VEGFR2. Soluble forms of these receptors sequester plasma VEGF, decreasing the amount available to bind to EC-bound receptors. Ramifications of surgery-related plasma VEGF changes partially depend on plasma levels of sVEGFR1 and sVEGFR2. This study assessed perioperative sVEGFR1 and sVEGFR2 levels after MICR in patients with colorectal cancer. Forty-five patients were studied; blood samples were taken from all patients preoperatively (preop) and on postoperative days (POD) 1 and 3; in most a fourth sample was drawn between POD 7–30. Late samples were bundled into two time points: POD 7–13 and POD 14–30. sVEGFR1 and sVEGFR2 levels were measured via ELISA. sVEGFR2 data are reported as mean ± SD and were assessed with the paired samples t test. sVEGFR1 data were not normally distributed. They are reported as median and 95% confidence interval (CI) and were assessed with the Wilcoxon signed-Rank test ( p < 0.05). Preoperatively, the mean plasma sVEGFR2 level (7583.9 pg/ml) was greater than the sVEGFR1 result (98.3 pg/ml). Compared with preop levels, sVEGFR2 levels were significantly lower on POD 1 (6068.2 pg/ml, ±2034.5) and POD 3 (6227.6 pg/ml, ±2007.0), whereas sVEGFR1 levels were significantly greater on POD 1 (237.5 pg/ml; 95% CI, 89.6–103.5), POD 3 (200.2 pg/ml; 95% CI, 159–253), and POD 7−13 (102.9 pg/ml; 95% CI, 189.7–253). No differences were found on POD 7–13 for sVEGFR2 or POD 14–30 for either protein. sVEGFR2 values decreased and sVEGFR1 levels increased early after MICR; sVEGFR2 changes dominate due to their much larger magnitude. The net result is less plasma VEGF bound by soluble receptors and more plasma VEGF available to bind to ECs early after surgery. [ABSTRACT FROM AUTHOR]

Plasma vascular endothelial growth factor (VEGF) levels are elevated for 2–4 weeks after minimally invasive colorectal resection (MICR). VEGF induces wound and tumor angiogenesis by binding to endothelial cell (EC)-bound VEGF-receptor 1 (VEGFR1) and VEGFR2. Soluble receptors (sVEGFR1, sVEGFR2) sequester VEGF in the blood and decrease VEGF’s proangiogenic effect. The importance of the MICR-related VEGF changes depends on the effect of surgical procedures on sVEGFR1 and sVEGFR2; this study assessed levels of these proteins after MICR for benign indications. Blood samples were taken ( n = 39) preoperatively (preop) and on postoperative days (POD) 1 and 3; in most cases a fourth sample was drawn between POD 7 and 30. sVEGFR1 and sVEGFR2 levels were measured via enzyme-linked immunosorbent assay (ELISA), which detects free and VEGF bound soluble receptor. Late samples were bundled into POD 7–13 and POD 14–30 time points. Results are reported as mean and standard deviation. The data was assessed with paired-samples t-test. Preop, mean plasma sVEGFR2 level (9,203.7 ± 1,934.3 pg/ml) was significantly higher than the sVEGFR1 value (132.5 ± 126.2 pg/ml). sVEGFR2 levels were significantly lower on POD 1 (6,957.8 ± 1,947.7 pg/ml,) and POD 3 (7,085.6 ± 2,000.2 pg/ml), whereas sVEGFR1 levels were significantly higher on POD 1 (220.0 ± 132.8 pg/ml) and POD 3 (182.7 ± 102.1 pg/ml) versus preop results. No differences were found on POD 7–13 or 14–30. sVEGFR2 values decreased and sVEGFR1 levels increased early after MICR; due to its much higher baseline, the sVEGFR2 changes dominate. The net result is less VEGF bound to soluble receptor and more free plasma VEGF. [ABSTRACT FROM AUTHOR]

Introduction from the Editor An international working party co-ordinated by Dr Ann Lowry, University of Minnesota, was charged with the task of producing definitions of terms applicable to anorectal physiology and rectal cancer. The consensus achieved is published below and will simultaneously appear in Diseases of Colon and Rectum and in the Australian New Zealand Journal of Surgery. It is essential that there is uniformity in descriptions and it is hoped that the Statement will be generally adopted and become standard terminology. [ABSTRACT FROM AUTHOR]

OBJECTIVES: to briefly outline the development and validation of the Parkinson's Disease Questionnaire (PDQ-39) and then to provide evidence for the use of the measure as either a profile of health status scores or a single index figure. DESIGN: the PDQ-39 was administered in two surveys: a postal survey of patients registered with local branches of the Parkinson's Disease Society of Great Britain (n = 405) and a survey of patients attending neurology clinics for treatment for Parkinson's disease (n = 146). Data from the eight dimensions of the PDQ-39 were factor-analysed. This produced a single factor on the data from both surveys. OUTCOME MEASURES: the eight dimensions of the PDQ-39 and the new single index score-the Parkinson's disease summary index (PDSI), together with clinical assessments (the Columbia rating scale and the Hoehn and Yahr staging score). RESULTS: in the postal survey 227 patients returned questionnaires (58.2%). AH 146 patients approached in the clinic sample agreed to take part. Higher-order principal-components factor analysis was undertaken on the eight dimensions of the PDQ-39 and produced one factor on both datasets. Consequently it was decided that the scores of the eight domains could be summed to produce a single index figure. The psychometric properties of this index were explored using reliability tests and tests of construct validity. The newly derived single index was found to be both internally reliable and valid. DISCUSSION: data from the PDQ-39 can be presented either in profile form or as a single index figure. The profile should be of value in studies aimed at determining the impact of treatment regimes upon particular aspects of functioning and well-being in patients with Parkinson's disease, while the PDSI will provide a summary score of the impact of the illness on functioning and well-being and will be of use in the evaluation of the overall effect of different treatments. Furthermore, the PDSI reduces the number of statistical comparisons and hence the role of chance when exploring data from the PDQ-39. [ABSTRACT FROM AUTHOR]

The purpose of this paper was to document the impact of Parkinson's disease (PD) upon patients using both a generic health status measure (the Short-form 36 health survey questionnaire, SF-36) and a disease-specific measure (the 39-item Parkinson's Disease Questionnaire, PDQ-39). Comparing the results of the SF-36 in this population with a similar aged group selected randomly from two general practices it was evident that the disease has considerable impact on general levels of functioning and well-being. Furthermore, other areas not contained on the SF-36 were found to be relevant to PD patients. It is suggested that the disease-specific measure will be of value, ideally alongside a generic measure, in studies aimed at determining the impact of a treatment regimen upon PD patients, or to monitor the long-term progress of cohorts of patients with PD. The paper highlights the need for careful consideration of measures for evaluation. [ABSTRACT FROM AUTHOR]